Norwegian Involvement in RBF

Ingvar Theo Olsen, Norad

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Agenda

1. World Bank Trust Fund HRIG

2. Bilateral MDG 4 and 5 programme3. GAVI4. Global Fund for AIDS, TB and Malaria (GFATM)

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Results-based financing can be used at any level but it must trickle down to the point of contact between the provider and household to impact results

Donors

N ationa l G overnm

ent

Households or Individuals

Results Based Aid

Results Based Financing

CCP, CCT, RB bonusesProviders

Health CentersHospitals

S ub-nationa l

R eg ion/D is tric tResults Based

Budgeting and Financing

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World Bank Multi Donor Trust Fund Health Result Innovation Grant

• Established in 2007, focusing on MDG 4, 5 and 1 c • Improve health results through strengthening health systems• Explore value of RBF as a tool • Norwegian support NOK 580 million over 5 years• Norway so far the only donor, AUSAID interested

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•Incentives for pregnant women (transp., food in del. waiting rooms, etc.)

•Fin. incentives for immunization, growth monitoring, check-ups, absence of FGM

•Ann. lottery for those fulfilling the above

Demand side

Performance incentives for:•Regional health authorities for MCH targets

•MOH based on national MCH targets

Contracting to NGOs: •Performance-linked bonus to deliver basic package of health services

•Complementary bonus for hospitals for maternal and child services

Supply side

- Under utilization of reproductive and child health services

•Health system barely functioning after Taliban

•Govt started contracting with NGOs to deliver basic package of health care

Problem/context

EritreaAfghanistanWorld B ank HR IG

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•League table competition for Comm. Health Committees non-financial awards

•Combined transport subsidy and non-financial incentives to promote inst. deliveries and post-natal visits

•Incentives for pregnant w. to use MCH

•Community incentives to do interventions for MDG4, incl. family planning

Target based performance incentives for DHMT, facility teams, CHW, TBAs

•Incentives for female health workers to work in rural areas

•Progress on reducing IMR/U5MR slow, MMR increasing

•Coverage low due to human resources, absenteeism, etc. and barriers to utilization

•One of the highest rates of IMR and U5MR

•Current RBF program on supply-side, limited impact on deliveries, not covering demand

ZambiaRwanda

Demand side

Supply side

Problem/context

World B ank HR IG

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RBF in the Norwegian bilateral MDG 4&5 initiative:• Initiative by Prime Minister Jens Stoltenberg to contribute towards the millennium

development goals for health

• Global efforts – Global Leaders’ Network– Sherpa group

• Country efforts in 4-5 countries based on potentials for major impact on MDG 4 & 5:

Tanzania: Sector Wide Apporach programme (SWAp) with Government and DPs India: Support to National Rural Health Mission (NRHM) in five states Pakistan: Support to 10 districts in a province in the NorthNigeria: Support to programmes in 3-4 states in North, channelled through DFID

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Tanzania (NTPI)Problem:

MMR 578/1 00,000 live births, high newborn MRLow percentage of assisted births (health facility)Poor quality services, poorly motivated staff

S upply s ide R B F • Bonuses for health facilit ies (for health workers) at different levels

(dispensary, health centres, hospitals, CHMT, RHMT) • Based on achievements at institution på måloppnåelse for institusjonen• National universal targets for five indicators: OPV 0, DPT 3, IPT 2, facility

deliveries, HMIS complete and submitted in time

Objec tive: To motivate health workers to improve quality of services related to maternal and child health in order to attract more pregnant women

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... Tanzania (NTPI)

• Owned by MOHSW, funds channelled through SWAp basket arrangement

• Monthly reporting directly to president Kikwete• Full national rollout without pilot!• Many actors/stakeholders in the SWAp and basket• Different components (training, management, data validation,

HMIS strengthening, process evaluation, impact evaluation)• Final phases of programme development – implementation

starting

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India (NIPI)Problem:

High maternal- and newborn mortality, low share delivering in health centres/hospitals (major changes taking place)...

Supply side (NIPI) • Bonus for voluntary female health workers with low training (ASHA

og YASHODA)• Focus on infant and child health (as well as maternal)Demand side (NRHM) : • Cash incentives for women to deliver in facilit ies (etc.) Objective: • To motivate voluntary health workers to improve quality and follow-

up of maternal- and child health services• Encourage women to utilize health services

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India (NIPI)• NIPI supports NRHM in 5 states with 60% of India’s under five

mortality• NIPI offers flexible financing – money that can be used in

catalytic, strategic or innovative ways• The funds are channelled through thre UN agencies: UNOPS,

UNICEF & WHO• RBF much used in NRHM:

– supply and demand based– Institutional deliveries– PPP – engaging obstetrics – Improve health services for infants (NIPI – Yashoda and ASHA)

• Need for formal evaluations

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Pakistan (NPPI)Problem:• High maternal- and newborn mortality, poor quality and access to

health services resulting in low utilization ratesS upply s ide R B F:• Increased access to MCH services through result based contracts

(PPPs)• Improved governance and result based managementDemand s ide:• Incentives/vouchers to pregnant women to deliver at facility Objec tives :• Improve empowerment of women (increase awareness/choice re

own health) • Increase access to and quality of MNCH services• Increase administrative capacity and quality of health care systems

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Pakistan (NPPI)

• Sindh province – 1 0 rural districts• Strategic and catalytic support to achieve MDG 4&5• Via UN (”One UN” country)• RBF scheme to increase access, quality, demand for improved

MNCH services• Voucher init iative:

– remove economic barriers – pilot and eventually scale-up

• How can perverse incentives be avoided– anti corruption, good governance and mgt capacity – Strengthen HMIS, evaluation mechanisms and research

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Immuniza tio

n S ys te

m (IS S )

The V ac c ine Fundfund raising, advocacy,

additional resources to countries

National systems Preparing applications, implementation, monitoring and evaluation

G AV I board(M ultila tera l, bila tera le donors , res earc h ins t.,

vac c ine indus try, c ivil s oc iety)

Propos a ls-

M onitoringR eports

Independent R eview C ommittee review of country proposals,

monitoring reports

Technical support from partners (WHO, UNICEF etc.)

N ewvac c in

es

S a fety s uppli

es

GAVI

Hea lth s ys te

ms

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GAVI ISS - (Result based Aid)• N orw eg ian s upport N OK 500 million per year• Applic a tion bas ed

– Countries with GDP per capita below US$1 000 are eligible for ISS funding from GAVI in a five year perspective (i.e. R es ult-bas ed A id)

• Inves tment– The two first years a country receives support as an investment calculated

as number of additional children to be vaccinated, with baseline current year

• R ew ards– The third year countries receive support based on actual achievements– $20 per additional vaccinated child over the baseline in the application

• R es ult indic a tor– # children > 1 year that have been vaccinated with DPT3

• Externa l va lida tion of da ta– Validation of data through Data Quality Audits (DQA) carried out by audit

firms

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Results• 36 of 51 c ountries w ith approved applic a tions qua lified for

rew ards • Qualification depending on:

– achievements re number of children vaccinated – that country reports on results are accepted in an external data validation test

• Most of the countries that did not receive the reward did not pass the data quality test, whereas others did not vaccinate enough children

• V ac c ination c overag e meas ured by DTP3 in G AV I c ountries has inc reas ed – DTP3 – from 64% to 71 %

• Poverty orienta tion and reduc ed inequities– poor countries and countries with poor coverage have received a larger

proportion of GAVI funds– urban/rural inequity has been reduced– gender inequities have been reduced

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Conclusion: Findings from the evaluation could not conclude that the positive results can be attributed to the result based aspects of the GAVI ISS– Flexibility of funds may in itself be attributable– Countries with good results had strong partners that provided sound technical support, etc.

– Population growth in itself was the basis for the major share of the number of children vaccinated

Latest: Recent Lancet article by Chris Murray indicates data fraud with routine data reporting for GAVI ISS. Survey data model indicates over reporting from countries, linking this to result based financing.

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GFATM - RBF

• Norwegian support 2008: NOK 375 million• Application based (reviewed by independent panel and approved

by Board)• Support for 2 years – followed by phase 2 application (total 5

years) • Local Fund Agent (intl. audit firm) reviews and validates invoices

and report the results back to GFATM • Results end in recommendation to the Board: ”go”, ”condit ional

go”, ”no go” • The system is basically flexible, based on local conditions, the

harmonization agenda and existing best practices